Code of Federal Regulations Title 19. Customs Duties § 19.210.68—Affidavit by Individual Surety

United States International Trade Commission Affidavit by Individual Surety 19 CFR 210.68

State of

County

SS:

I, the undersigned, being duly sworn, depose and say that I am a citizen of the United States, and of full age and legally competent;  that I am not a partner in any business of the principal on the bond or bonds on which I appear as surety;  and that the information herein below furnished is true and complete to the best of my knowledge. This affidavit is made to induce the United States International Trade Commission to accept me as surety on the bond(s) filed or to be filed with the United States International Trade Commission pursuant to 19 CFR 210.68. I agree to notify the Commission of any transfer or change in any of the assets herein enumerated.

1. Name (First, Middle, Last)

2. Home Address

3. Type & Duration of Occupation

4. Name of Employer (If Self–Employed)

5. Business Address

6. Telephone No.

Home

Business

7. The following is a true representation of my assets, liabilities, and net worth and does not include any financial interest I have in the assets of the principal on the bond(s) on which I appear as surety.

^* Do not include property exempt from execution and sale for any reason. Surety's interest in community property may be included if not so exempt.

8. LOCATION AND DESCRIPTION OF REAL ESTATE OF WHICH I AM SOLE OWNER, THE VALUE OF WHICH IS IN LINE a, ITEM 7 ABOVE¹

Amount of assessed value of above real estate for taxation purposes:

9. DESCRIPTION OF PROPERTY INCLUDED IN LINE d, ITEM 7 ABOVE (List the value of each category of property separately)²

10. ALL OTHER BONDS ON WHICH I AM SURETY (State character and amount of each bond;  if none, so state)³

11. SIGNATURE

12. BOND AND COMMISSION INVESTIGATION TO WHICH THIS AFFIDAVIT RELATES

SUBSCRIBED AND SWORN TO BEFORE ME AS FOLLOWS:

DATE OATH ADMINISTERED

MONTH DAY YEAR

CITY

STATE (Or Other Jurisdiction)

NAME & TITLE OF OFFICIAL

ADMINISTERING OATH

SIGNATURE

MY COMMISSION EXPIRES

INSTRUCTIONS

1. Here describe the property by giving the number of the lot and square or block, and addition or subdivision, if in a city, and, if in the country, after showing state, county, and township, locate the property by metes and bounds, or by part of section, township, and range, so that it may be identified.

2. Here describe the property by name so that it can be identified—for example “Fifteen shares of the stock of the “National Metropolitan Bank, New York City,” or “Am. T. & T. s. f.5's 60.”

3. Here state what other bonds the affiant has already signed as surety, giving the name and address of the principal, the date, and the amount and character of the bond.